It is quite common for patients with migraine and headaches to have a coexisting psychiatric co-morbidity, such as anxiety or depression. In fact, headache and psychological distress share the same risk factors, such as environmental stressors and genetic predisposition. Headache history may predispose a patient to psychopathology and psychopathology may predispose a patient to headache. Which comes first varies person to person, always a little different. In adults, longitudinal studies have provided evidence for bidirectional associations between psychopathology and headache.
Genetic predisposition can apply to both the patient and/or parents, related to migraine and headache, as well as depression, anxiety, and bipolar disorder. It is possible that depression and migraine may partly share underlying genetic risk factor. Often these disorders can be seen all throughout the family tree.
When we talk about environmental stressors, there are many to be considered in pediatrics. Common stressors include: Personal exposure to physical, psychological or sexual violence, neglect in the home, school or community (witnessing domestic violence, bullying), other forms of adversity (losses, poverty, disease), and lack of meaningful social supports.
Teens can respond to these stressors with:
- internalizing (anxiety, depression, PTSD, eating disorder, social withdrawal, isolation, and loneliness, low self esteem)
- externalizing (antisocial behavior, problems with attention, concentration, hyperactivity, substance abuse, smoking)
- somatic complaints (headache, other pain complaints, overweight, insomnia).
The result of exposure to such stressors can be adaptive or maladaptive development, coping and functioning. We know that stress is the most common migraine trigger. It also is a cause of stress or tension-type headache. Chronic daily headaches with all day, every day pain is made worse in times of stress. The key is to recognize the situation and therapeutically intervene to promote adaptive coping and resilience.
Kids and teens are generally open to working with a therapist, especially when the emphasis is on skills-based techniques, like cognitive behavioral therapy or biofeedback, rather than ‘talking about my feelings’. Oftentimes, this type of therapy is enough to promote better coping. The addition of psychotropic medication can certainly help but the personal connection really enhances the effect of the techniques.
Unfortunately in these times, finding a therapist is difficult, with the almost epidemic level of anxiety in our kids these days. They can be directed towards apps but the personal touch is always best. Our pain psychologists have developed a program, becoming more available through the nation, called The Comfortability program, which works with kids and their parents in learning pain coping strategies, based on CBT. Check it out at: http://www.thecomfortability.com/
In addition, there is a role for psychopharmacology for both the treatment of mental health concerns and for pain and headache. Ideally, individual psychotherapy/counseling would be established either before or in conjunction with the start of a psychotropic medication.
I’ll cover psychopharmacology in Headaches and psychiatric Co-morbidities, Part 2.
